Sample ICF Chart – 6 year old male

HEALTH CONDITION

L3 Myelomeningocele (Spina Bifida)– 6 years old male

Arnold Chiari II Malformation with hydrocephalus with VP
Shunt placement
Bilateral club feet (congenital talipes equinovarus)
Bilateral Hip Dysplasia
ACTIVITY (TASKS)
BODY STRUCTURES/FUNCTION PARTICIPATION
(IMPAIRMENTS) Abilities Limitations
1. Brain and CNS 1. Can’t climb steps
Abilities Restrictions
a. Arnold Chiari II Malformation 1. Walks independently on independently with
1. Attends school with 1. Limited ability to interact
with Impaired cognitive level surfaces with HKAFO and crutches.
same age peers with peers due to difficulty
functions impacting motor HKAFO and forearm 2. Difficulty keeping up
2. Plays recreational with long distance mobility,
planning abilities crutches. with peers due to slow
adaptive soccer with speed and endurance.
b. Peripheral nerve involvement of 2. Climbs in/out of tub with ambulatory speed.
peers
lower extremities. supervision
3. Participates in all family
1. Lower extremity paralysis 3. Transfers and
activities and outings
2. Impaired sensation in transitions
both lower extremities independently
a. With HKAFOs braces -
2. Musculoskeletal involvement of floor to standing and sit to
lower extremity- legs and feet standing with upper
a. Bilateral Hip Dislocation due to extremity assistance
Hip dysplasia b. Without HKAFOs braces-
b. Impaired lower extremity ROM transfers in and out bed and
and joint contractures with chair as well as to/from the
bilateral hip flexion contractures tub chair
c. Car transfers –transfers in
and out of the car with
supervision from w/c
to/from the car.
ENVIRONMENTAL

Internal External
+ - + -
1. Above average 1. Impaired cognitive function 1. Supportive and Limitation due to structural
intelligence due to hydrocephalus motivated parents and environmental access.
motivated to learn resulting in motor planning 2. Supportive school a. school bus access is
and move impairment. system not available to due
2. Very motivated to 2. Limited LE function 3. Followed in a not owning a
learn, move and multidisciplinary wheelchair which is
engage with his clinic. required to ride the
 peers. 4. Support from 3rd bus.
3. Has a very social party payers b. Structural barriers
personality including private due to building, etc.
insurance and state not being accessible.
Medicaid.
 Case Report

A Tool for Clinical Reasoning and

Reflection Using the International
Classification of Functioning, Disability
and Health (ICF) Framework and
Patient Management Model
Heather L. Atkinson, Kim Nixon-Cave
H.L. Atkinson, PT, DPT, NCS, is
a clinical specialist in the De-
partment of Physical Therapy,
Background and Purpose. Professional development is a cornerstone of
The Children’s Hospital of Phila- physical therapist practice. As the profession moves toward the ideals of Vision 2020,
delphia, 34th and Civic Center more emphasis is being placed on the process of clinical decision making. Although
Blvd, Philadelphia, PA 19104- reflection and mentorship are widely regarded as important instruments to facilitate
4399 (USA). Address all corre- the progression of clinical reasoning skills, little guidance exists in the postprofes-
spondence to Dr Atkinson at:
sional arena to assist clinicians with these essential needs. As more organizations
AtkinsonH@email.chop.edu.
develop formal mentoring programs, a need arises for a tool that will engage mentors,
K. Nixon-Cave, PT, PhD, PCS, is protégés, and clinicians of all abilities in thoughtful reflection and discussion that will
Manager of Physical Therapy,
help develop clinical reasoning skills.
Department of Physical Therapy,
The Children’s Hospital of
Philadelphia. Case Description. The process of developing reflective clinical decision-making
skills in physical therapist practitioners is described, and how this process was used
[Atkinson HL, Nixon-Cave K. A
tool for clinical reasoning and at one institution is illustrated. A tool for clinical reasoning and reflection is proposed
reflection using the International that incorporates the existing conceptual frameworks of the Guide to Physical
Classification of Functioning, Dis- Therapist Practice and the International Classification of Functioning, Disability
ability and Health (ICF) framework and Health (ICF).
and patient management model.
Phys Ther. 2011;91:416 – 430.]
Outcomes. This case report discusses how the tool was implemented by staff
© 2011 American Physical Therapy with varying levels of expertise, their outcomes in regard to the development of their
Association
clinical reasoning skills, and how the tool facilitated mentoring sessions around
patient cases to improve care.

Discussion. This case report describes a practical application of a post-

professional educational process designed to develop reflective and patient-centered
clinical reasoning skills. Although this process has shown some preliminary success,
more research is warranted. By cultivating reflective thinking and critical inquiry, the
physical therapy profession can help develop autonomous practitioners of physical
therapy and promote the ideals of Vision 2020.

Post a Rapid Response to

this article at:
ptjournal.apta.org

416 f Physical Therapy Volume 91 Number 3 March 2011

 Clinical Reasoning and Reflection

V
ision 2020, as set forth by the practice, CDM models, clinical rea- 3. Develop a guide or process for
American Physical Therapy soning approaches, and a model of clinical mentoring of clinicians at
Association (APTA), highlights disablement and functioning. The all levels.
the following elements: autonomous physical therapy profession has used
physical therapist practice, direct a variety of conceptual frameworks, 4. Integrate the ICF framework into
access, the doctor of physical ther- most recently the APTA’s Guide to the CDM process using the Guide
apy degree and lifelong education, Physical Therapist Practice3 and to Physical Therapist Practice as
evidence-based practice, practitio- the International Classification of a structural base.
ner of choice, and professionalism.1 Functioning, Disability and Health
As the physical therapy profession (ICF) as set forth by the World Target Setting
strives to reach these goals, more Health Organization.4 This tool was developed for use in a
emphasis is being placed on the pro- large academic hospital network
cess of clinical decision making Clinical reflection and mentorship providing physical therapy through-
(CDM) and professional develop- are routinely recognized as impor- out the continuum of care including
ment, while using evidence and tant components of professional acute care, inpatient rehabilitation,
reflection to guide clinical decisions. development5,6; however, little general outpatient rehabilitation,
structure exists to guide clinicians and sports medicine. Our staff com-
Common types of clinical decisions through this complex process. While prises more than 65 full-time and
include: in the development stage of launch- part-time therapists with a range of
ing a pediatric residency program, experience, from new professionals
• Who needs treatment and why? we recognized the need for a clinical to those in later career practice with
• What are the expected outcomes of reasoning and reflection tool that more than 30 years of experience.
intervention? could serve not only as a reflection We currently employ more than 30
• How should outcomes be mea- guide for the resident but also to board-certified specialists recog-
sured and documented? facilitate mentoring sessions. While nized by the American Board of Phys-
• What intervention, instructions, pilot testing the tool with the resi- ical Therapy Specialties (ABPTS) in
services, and number of visits are dent, it became apparent that it also cardiopulmonary, pediatrics, neurol-
necessary to meet these outcomes? could benefit clinicians of all abilities ogy, orthopedics, and sports medi-
• How should the patient and care- in their journey from novice to cine specialties and have recently
givers be included in the decision- expert practitioners, as great empha- developed a pediatric residency pro-
making process? sis is placed on using reflection and gram. As part of our department’s
• How should the success of the existing clinical models to make bet- vision for professional development,
intervention and cost-effectiveness ter decisions about patient care. this clinical reflection tool was initi-
be evaluated? ated to help novice and master clini-
• Are referrals needed for other The purpose of this case report is to cians alike in their personal quest
health care services and screen- describe the process of developing for professional development and
ings? reflective CDM skills for physical to facilitate a formalized mentorship
therapist practice within the context program.
Clinical decision making is a very of the Guide to Physical Therapist
complex, uncertain, evaluative, sci- Practice and the ICF framework. Development of the
entific process2 that can be costly, This report illustrates case examples Process
with a lot of intuition, in an effort to in which this process was used in In preparing for the development of
provide best practice. Physical ther- our institution. Finally, this article our residency and mentoring pro-
apists strive to make decisions that proposes the use of a tool that can be
include all aspects of expert prac- used in any setting to facilitate the
tice, including knowledge, core val- following goals: Available With
ues, clear clinical reasoning, and This Article at
excellent clinical practice skills 1. Assist in the development of CDM ptjournal.apta.org
focused on providing high-quality, skills of physical therapist
patient-centered care. practitioners. • Audio Abstracts Podcast
This article was published ahead of
In making clinical decisions, physical 2. Facilitate a reflective process in print on January 27, 2011, at
therapists rely on a conceptual CDM that includes critical inquiry ptjournal.apta.org.
framework that includes theories of and the use of evidence.

March 2011 Volume 91 Number 3 Physical Therapy f 417

Clinical Reasoning and Reflection

gram, a literature search was per- lighted the interplay between knowl- conceptual models and case exam-
formed and important concepts edge and reasoning.9 ples that utilize the ICF as a basis for
were realized regarding the topics of decision making.13–17 Recently,
clinical reasoning, models of CDM in In 2003, APTA put forth the Guide to Escorpizo and colleagues12 sug-
physical therapy, reflection, mentor- Physical Therapist Practice (2nd edi- gested a method to integrate the ICF
ship, and expert physical therapist tion), which offers the patient man- into clinical practice documentation.
practice. A common element that agement model as a conceptual As the profession and the Guide to
continually arose was that although framework for clinical decision mak- Physical Therapist Practice evolve
structure or a concrete approach is ing and includes all elements of phys- and seek new ways to integrate the
regarded as very important in both ical therapist practice, including ICF, it becomes important for the
the clinical reflection and mentoring examination, evaluation, interven- clinician to have a practical tool that
process, little exists in the profes- tion, and outcomes.3 This model pro- uses both the ICF and the Guide to
sional community in the way of a vides an overall concept map for Physical Therapist Practice in an
guiding tool or worksheet to facili- practice in any setting and with any integrative manner to probe reflec-
tate this process. patient population. The Guide to tion and reasoning in order to pro-
Physical Therapist Practice also uses mote best patient outcomes.
Clinical Reasoning and the Nagi model of disablement,3
Models of Decision Making which centers on the concepts of Clinical Reasoning
Clinical reasoning has been defined pathology, impairment, functional Strategies Used in the
as “an inferential process used by limitation, and disability, as a founda- Patient Management
practitioners to collect and evaluate tion. By using the Nagi model with
data and to make judgments about the patient management model, cli-
Model
Knowledge garnered from research
the diagnosis and management of nicians are able to prioritize prob-
in the field of clinical reasoning and
patient problems.”7(p101) Clinical rea- lems in a patient-centered method
decision making can be directly
soning includes the application of and to better understand what prob-
applied to the patient management
cognitive and psychomotor skills lems are most important to the
model in a way that integrates the
based on theory and evidence, as patient.
ICF. Clinical reasoning strategies
well as the reflective thought pro-
may differ in the various domains of
cess, to direct individual changes More recently, the profession has
the model, depending upon the spe-
and modifications called for in spe- adopted the ICF as a framework to
cific situation and the knowledge
cific patient situations.8 Current approach patient care that shifts the
and expertise of the clinician. Clini-
research in clinical reasoning sug- conceptual emphasis away from neg-
cians also may use dialectical reason-
gests that the process of applying ative connotations such as disability
ing, an ability to use a variety of rea-
knowledge and skill, integrated with and places focus on the positive abil-
soning strategies for a single
the intuitive ability to vary an exam- ities of the individual at the patient
situation.18
ination or treatment based on reflec- level rather than the systems lev-
tion and interaction to achieve a suc- el.4,11 The ICF framework is a classi-
Examination
cessful outcome for an individual fication of the health components
Forward reasoning, or pattern recog-
patient, is what separates experts of functioning and disability and
nition, often is used when identify-
from novices as it relates to the cli- focuses on 3 perspectives: body,
ing salient qualitative information.19
nician’s approach to reasoning.8 –10 individual, and societal.4 These 3
In the medical field, much attention
Jensen and colleagues9 described in perspectives underscore the impor-
has been afforded to the speed and
detail the attributes of both novice tance of the interplay and influence
accuracy with which expert practi-
and master clinicians and proposed 4 of both internal and external factors
tioners can recognize patterns and
dimensions to characterize expert to each individual’s condition of
formulate hypotheses.18,20 Clinicians
physical therapist practice: (1) mul- health.4
also may use backward reasoning, or
tidimensional and patient-centered
hypothesis-guided inquiry, which
knowledge; (2) collaborative and Since the introduction of the ICF
assists the practitioner in systemati-
reflective clinical reasoning; (3) as a conceptual framework, physical
cally negating or supporting gener-
observational and manual skill in therapists in the United States have
ated hypotheses.19 This concept is
movement, with a focus on function; been slow to fully adopt it as an
central to the science and skill of
and (4) consistent virtues. The approach to patient care.12 To facil-
differential diagnosis. McGinnis et
authors illustrated the connection itate using the ICF in practice, sev-
al21 suggested that a nonlinear
between these realms and high- eral practitioners have proposed

418 f Physical Therapy Volume 91 Number 3 March 2011

 Clinical Reasoning and Reflection

thought process is involved in select- reasoning skills to effectively improved quality of care. Further-
ing specific tests and measures for appraise and integrate evidence into more, it may not be necessarily years
balance assessment. They described practice is essentially linked to of experience that lead to clinician
3 stages of clinical reasoning: (1) ini- Vision 2020. becoming an expert, but rather it is
tial impressions and movement the development of advanced CDM
observation, (2) data gathering, and Outcomes that leads to the expertise associated
(3) diagnosis and treatment plan- A key component of the clinical rea- with improved patient outcomes and
ning. Interestingly, the therapists soning process in generating suc- quality of life.23
involved in their study frequently cessful outcomes is collaboration
looked ahead to their possible diag- with the patient.9,22 Resnik and Reflection
noses and treatment plans when Hart23 ascertained that physical ther- Clinical reflection is a powerful tool
selecting tests and measures during apy expertise is not based on years in developing clinical reasoning
the examination, all while consider- of experience and is rather more skills and professional growth.5,6,18,19
ing patients’ values and beliefs and closely linked with health-related Reflection is a necessary skill in
being guided by ethical and legal quality-of-life outcomes and patient learning and metacognition.25 Meta-
aspects of professional practice.21 satisfaction. Emphasizing patient cognition is defined as an “aware-
empowerment through active partici- ness or analysis of one’s own learn-
Evaluation pation, education, and collaborative ing or thinking processes.”26 This
The clinician next synthesizes quali- reasoning is the hallmark of expert “thinking about thinking” has been
tative and quantitative information, physical therapist practice.22 linked to the cultivation of clinical
considers all of the factors described Specialty-certified physical therapists reasoning strategies.5,25 Schön
by the ICF framework, and generates also are more likely to use standard- described reflection as occurring
a diagnosis, prognosis, and plan of ized outcome measures to make either “in action,” during the event,
care. Prioritizing patient problems decisions about practice.24 Jette and or “on action” after the event.27 Both
and linking them to the ICF frame- colleagues24 found that although processes require metacognitive
work are essential in determining if many physical therapists routinely thinking and can be enhanced by
and how physical therapy may ben- recognize the importance of measur- special instructive techniques. A
efit the patient. Developing a flow- ing outcomes, standardized outcome unique strategy to augment reflec-
chart or concept map may help to measures are significantly under- tion in action is the “think-aloud”
organize information in a meaningful used. They suggested that focused approach for either the learner or
way.19 Conceptual mapping also can education, for both students and the mentor in a given situation.25,28
help illuminate which prob- practicing professionals, may be nec- Having a novice clinician think aloud
lems are most important to the essary to enculturate the standard during a clinical encounter can help
patient, which problems are the larg- use of outcome measures in the mentor identify areas where rea-
est barrier to the next level of func- practice.24 soning strategies may be improved.25
tion, and which problems may be In addition, the articulation of clini-
most affected by physical therapy Physical therapists utilize a variety of cal reasoning can facilitate the meta-
intervention. CDM strategies that incorporate a cognitive process.25 The mentor also
classification system such as the ICF may choose to think aloud during a
Intervention throughout the various elements of clinical encounter to give novice cli-
Selection and progression of specific physical therapist practice. Knowl- nicians insight into his or her reason-
procedural interventions are part of edge and psychomotor ability, ing strategies.28
a systematic clinical reasoning pro- including observational analysis, are
cess.19 Physical therapists must uti- important in the development of After the clinical encounter, strate-
lize competent clinical decision- higher-level skill demonstrative of gies to enhance learning and reason-
making skills when appraising the expert practice. Prospective or for- ing include both internal focused
available evidence in the effort to ward reasoning, deductive or back- reflection and external reflective
select the most appropriate treat- ward reasoning, concept mapping, articulation, either orally or in writ-
ment. Although scientific evidence is evidence appraisal, and interactive ing.29 External guided writing that is
emphasized in guiding decisions, cli- collaboration with the patient and reflective on action may take the
nicians also must make decisions family are important strategies for form of portfolios or journal
when receiving guidance from col- CDM, and greater proficiency in entries.5,29 A critical aspect of these
leagues or mentors or relying on past these skills frequently leads to an instructive techniques designed to
experience. Possessing the clinical elevated level of practice and promote reflection and improved

March 2011 Volume 91 Number 3 Physical Therapy f 419

Clinical Reasoning and Reflection

clinical reasoning is the use of struc- nificantly advance their preparation clinical reflection guide to probe rea-
ture.5 Although structured reflective to provide patient care in a defined soning throughout the various stages
learning experiences are common in area of practice.34 Planned postpro- of physical therapist practice. Fur-
physical therapy clinical education fessional clinical education programs thermore, although training work-
for students, little is known about such as these may more quickly shops are available to educate clini-
their use in the common workplace develop an advanced practitioner cians in the art of mentorship, little
for practicing clinicians. Wainwright and can potentially accelerate the specific direction is available to
and colleagues6 studied differences process of developing from a novice help mentors generate questions for
in how novice and experienced cli- to a master clinician.33,35 Structured protégés regarding patient case
nicians use reflection in the CDM reflection and mentorship are funda- examples.
process. They observed that mental to the success of these pro-
although novice clinicians are more grams and ultimately support the Physical Therapy Clinical
likely to reflect on the specific situa- Vision 2020 goal of physical thera- Reasoning and Reflection
tion in front of them, experienced pist as practitioner of choice. Tool
clinicians often reflect on a broader, The Physical Therapy Clinical Rea-
deeper scale, bringing in past expe- Although residency and fellowship soning and Reflection Tool (PT-CRT)
rience and thinking about the wider programs seek to advance profes- (Appendix) was developed and is
scope of physical therapist practice.6 sional and clinical reasoning skills to proposed for use as a clinical reflec-
The authors suggested that this infor- the realm of expertise, access and tion tool and a guide for mentors,
mation can be helpful in designing availability are relatively limited. As a protégés, and clinical discussion.
mentorship experiences that facili- result, clinicians may seek structured The PT-CRT seeks to integrate the
tate professional development.6 mentorship programs outside of res- ICF framework into the patient man-
idencies and fellowships, with the agement model while incorporating
Mentorship goal of entering into either a mentor the hypothesis-driven basis of CDM
Mentorship is a cornerstone of pro- or protégé role to promote profes- models.13–15,37 Its design aims to
fessional development. In the prac- sional development. From a nursing probe reflection and discussion for
tice of health care, many disciplines perspective, Block and colleagues36 both the novice and master clinician
have written about the importance discussed that formal mentoring pro- and may be used as a mentoring tool
of the mentoring relationship in grams are important not only for per- for specific patient cases. Clinicians
professional growth and develop- sonal growth and development but may choose pertinent sections and
ment.30,31 Likewise, from a physical also for staff retention and overall questions to guide critical thinking
therapy perspective, mentorship is a organizational success. They advo- or may select to complete the work-
key element in the advancement of cated that organizations embrace the sheet in its entirety. The shaded
CDM skills, the promotion of both importance of formal mentorship boxes include suggestions to further
reflection in and on action, and pro- programs and encouraged allocation promote reflection or discussion
fessional development. The multidi- of the necessary financial and human with a mentor. They also may help to
mensional relationship between resources to ensure their success.36 identify further potential inquiries to
mentor and protégé has been explore, either by a review of the
revered as a crucial component of Clinical reflection, supported by evidence or by designing a new and
fostering professional growth.32 mentorship, is a key element in important clinical question.
Much has been published about the developing CDM skills. Reflection
key attributes of both mentors and and mentorship may take place Application of the Process
protégés and expected outcomes of either during or after a clinical The PT-CRT was pilot tested in the
the relationship.30 –32 A key element encounter and may include internal Pediatric Residency Program of the
of a successful mentoring relation- reasoning processes or external Children’s Hospital of Philadelphia.
ship and program is structure.19 articulation. Reflection and mentor- The resident reported that the tool
ship that are structured and planned helped to organize individual patient
The development of physical ther- lend themselves to a more compre- problems. By going through the
apy residency and fellowship pro- hensive and thoughtful learning reflection questions with her men-
grams have allowed for structured experience. Clinicians may use mul- tor, she felt she was making better
mentorship experiences.19,33 In resi- tiple reasoning strategies at one clinical decisions and developing a
dency or fellowship programs, prac- time, or use different strategies for a deeper understanding of the role of
ticing clinicians receive a planned given situation. Despite this knowl- physical therapy for her patients. Fig-
learning experience designed to sig- edge, little exists in the way of a ure 1 illustrates how the resident uti-

420 f Physical Therapy Volume 91 Number 3 March 2011

 Clinical Reasoning and Reflection

Figure 1.
Illustration of how the evaluation section of the Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) was utilized for a
17-year-old boy with leukemia and methotrexate toxicity. ADLs⫽activities of daily living.

lized the evaluation section of the (delayed cognitive processing) to treatment plan and advance the
PT-CRT for a 17-year-old boy with help the patient achieve his goals as patient toward his goals. Finally, the
leukemia and methotrexate toxicity. quickly as possible. When designing emphasis on outcomes and measure-
By using the structure provided by the intervention plan (Fig. 2), the ment guided the resident in selecting
the tool and identifying patient prob- resident initially was overwhelmed appropriate outcome measures that
lems within the context of the ICF, by the multitude of procedural inter- evaluated progress across all
the resident was able to reflect on ventions she wanted to implement domains of the ICF, allowing her to
the factors that were most important with this complex patient. However, evaluate the value of the interven-
to the patient, formulate a plan of by using the reflective questions in tions from a holistic and patient-
care, and identify other resources the intervention section of the centered perspective.
(ie, psychology, social work) to help PT-CRT and having a dialogue with
manage some of the factors outside her mentor, the resident was able to After pilot testing the PT-CRT in our
of the typical scope of physical ther- focus on and prioritize an evidence- residency program, the instrument
apy. The resident also was able to based intervention approach rooted was further trial tested with staff
identify environmental factors that in motor learning strategies such as members as part of the department’s
could be a facilitator or barrier to the task-specific training. The resident professional development program.
patient’s overall progress. By doing used the primary problem areas iden- Mentors received training through a
this, she accentuated the facilitators tified using the ICF and interaction workshop led by experienced clini-
(high motivation) and the barriers with the patient to individualize the cians and other mentors who dis-

March 2011 Volume 91 Number 3 Physical Therapy f 421

Clinical Reasoning and Reflection

VI. Interventions

a. Describe how you are using evidence to guide your practice

• Researched methotrexate toxicity to determine what to expect in terms of neurologic recovery
• Performed literature search for physical therapy interventions with leukemia
• Used articles and textbooks to guide motor learning strategy

b. Identify overall approach/strategy

• Will use motor learning theory; emphasize task-specific practice. Will consider:
• Feedback (intrinsic vs extrinsic, immediate vs delayed, knowledge of results vs knowledge of performance)
• Practice (whole vs part, random vs blocked, massed vs distributed, constant vs variable)
• Environment
• Recovery vs compensation
• Due to good potential for neurologic recovery from methotrexate toxicity, will emphasize recovery in interventions rather
than compensatory techniques

c. Describe and prioritize specific procedural interventions

• Task-specific practice
• Transfer training, bed mobility, ambulation
• Massed practice
• Increase number of steps by using body-weight support for locomotor training
• Strength training
• Progressive resistive exercises and proprioceptive neuromuscular facilitation techniques
• Use of neuromuscular electric stimulation on hip abductors/extensors in standing as an adjunct
• Aquatic therapy
• Use of water properties (buoyancy, resistance) to support and challenge return of neuromuscular motor control

d. Describe your plan for progression

• Will utilize concept of the “challenge point”; will continually reassess and progress activities so that as the patient achieves
success, he will be challenged further
• Will periodically reassess patient status with outcome measures across various levels of the ICF to help determine which areas
to prioritize during sessions:
• Body structures/function: Balance scale, Functional Reach Test, isometric strength testing
• Activities: Functional Improvement Measure, Dynamic Gait Index, Timed “Up & Go” Test
• Participation: Six-Minute Walk Test, quality-of-life self-assessment
• Will consider patient and caregiver goals, response to intervention, and positive and negative internal and external environ-
mental factors (what is most motivating, what is most important)
• Will perform brief systems review at beginning of each session to consider how various medical factors (blood counts, pain,
fatigue, avascular necrosis) may affect or be affected by physical therapy intervention

Figure 2.
Illustration of how the intervention section of the Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) was utilized for
a 17-year-old boy with leukemia and methotrexate toxicity. ICF⫽International Classification of Functioning, Disability and Health.

cussed general concepts of mentor- Outcome her mentor and the tool; this
ship, created role play opportunities, Although the PT-CRT is still in the advancement in skills was confirmed
and introduced the PT-CRT as a early stages of implementation, there by the residency committee during
mechanism to guide mentoring ses- are some promising outcomes to her last practical live patient exami-
sions. Both mentors and protégés report. The PT-CRT catalyzed our nation. She submitted a case study at
welcomed the concept of a work- first department resident to present a the 2011 APTA Combined Sections
sheet to facilitate clinical reasoning case study at the 2010 APTA Com- Meeting using the examples
and have reported success in using bined Sections Meeting and to pub- described in Figures 1 and 2.
the PT-CRT for mentoring discus- lish a Clinical Bottom Line.38,39 Our
sions as well as their own clinical second resident expressed a signifi- The PT-CRT has received positive
reflection. cant shift in CDM and credited both feedback from the rest of staff,

422 f Physical Therapy Volume 91 Number 3 March 2011

 Clinical Reasoning and Reflection

including mentors, protégés, and ultimately, improve outcomes for 5 Shepard KF, Jensen GM. Techniques for
teaching and evaluating students in aca-
department leadership. No negative the patients and clients they serve. demic settings. In: Shepard KF, Jensen
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ical Therapists. 2nd ed. Boston, MA: But-
have been identified. Different Although the initial data in this case terworth-Heinemann; 2002:71–132.
aspects of the tool seem to be impor- report are promising, more research 6 Wainwright SF, Shepard KF, Harman LB,
tant based on therapist experience is warranted. Collaboration among Stephens J. Novice and experienced phys-
ical therapist clinicians: a comparison of
and comfort with the patient case. residency and fellowship training how reflection is used to inform the clin-
For example, the hypothesis compo- sites to implement the PT-CRT and ical decision-making process. Phys Ther.
2010;90:75– 88.
nents of sections I and II helped to document outcomes through qualita-
7 Lee JE, Ryan-Wenger N. The “Think
advance reflection in a novice clini- tive methods could provide further Aloud” seminar for teaching clinical rea-
cian by prompting anticipation of information about the helpfulness of soning: a case study of a child with phar-
yngitis. J Pediatr Health Care. 1997;11:
the patient’s problems, and then the tool and the clinical reasoning 101–110.
probed further analysis of the accu- process being developed in these 8 Palisano RJ, Campbell SK, Harris SR.
racy of her predictions. Another cli- programs. Additionally, more Evidence-based decision making in pediat-
ric physical therapy. In: Physical Therapy
nician reported difficulty in generat- research is needed to evaluate the for Children. 3rd ed. St Louis, MO: Saunders-
ing a prognosis; he stated that PT-CRT’s effectiveness in different Elsevier; 2006:3–32.
examining the prognosis questions settings and how it may influence 9 Jensen GM, Gwyer J, Shepard K. Expert
practice in physical therapy. Phys Ther.
of the tool with his mentor improved the CDM process for physical ther- 2000;80:28 – 43.
his formulation of positive and neg- apists with different levels of 10 Jensen GM, Shepard KF, Gwyer J, Hack
ative prognostic indicators and expertise. Understanding how the LM. Attribute dimensions that distinguish
master and novice physical therapy clini-
helped him better understand the PT-CRT relates to the advancement cians in orthopedic settings. Phys Ther.
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prognosis. Finally, experienced staff provide further insight into the 2006;86:726 –734.
members have found the tool to be development of the autonomous, 12 Escorpizo R, Stucki G, Cieza A, et al. Cre-
helpful in recognizing their biases in reflective practitioner. ating an interface between the Interna-
tional Classification of Functioning, Dis-
certain patient cases. They also have ability and Health and physical therapist
reported that the PT-CRT can be Dr Atkinson and Dr Nixon-Cave provided
practice. Phys Ther. 2010;90:1053–1063.
extremely helpful when guiding a concept/idea/project design and writing. 13 Steiner WA, Ryser L, Huber E, et al. Use of
the ICF model as a clinical problem-
mentoring session. solving tool in physical therapy and reha-
Part of the manuscript, including the PT-CRT
bilitation medicine. Phys Ther. 2002;82:
Tool, was presented by both authors at an 1098 –1107.
Discussion educational session at the Combined Sec-
14 Palisano RJ. A collaborative model of ser-
The PT-CRT seeks to combine avail- tions Meeting of the American Physical Ther- vice delivery for children with movement
able resources in the profession into apy Association; February 11, 2011; New disorders: a framework for evidence-based
Orleans, Louisiana. decision making. Phys Ther. 2006;86:
a user-friendly and thought- 1295–1305.
provoking worksheet that fully inte- This article was submitted July 7, 2009, and 15 Schenkman M, Deutsch JE, Gill-Body KM.
grates the ICF into the CDM process. was accepted November 11, 2010. An integrated framework for decision
making in neurologic physical therapist
Physical therapists may use this tool DOI: 10.2522/ptj.20090226 practice. Phys Ther. 2006;86:1681–1702.
not only as a conduit to make deci- 16 Helgeson K, Smith AR Jr. Process for
sions about patient care but also as a applying the International Classification
References of Functioning, Disability and Health
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1 APTA Vision Sentence and Vision State-
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to stimulate discussions with a men- at: http://www.apta.org/vision2020. 17 Rundell SD, Davenport TE, Wagner T.
Accessed July 22, 2010. Physical therapist management of acute
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2 Watts NT. Clinical decision analysis. Phys
also may use the PT-CRT to identify Ther. 1989;69:569 –576. World Health Organization’s Interna-
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important clinical questions that 3 Guide to Physical Therapist Practice. 2nd ability and Health [erratum in: Phys Ther.
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19 Tichenor CJ, Davidson JM. Postprofes-
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20 Eva KW. What every teacher needs to 27 Schön DA. The Reflective Practitioner. 35 Hartley G. Postgraduate residency training
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Michlovitz SL. Factors that influence clini- Acad Med. 2003;78:322–325. frey R. The value of mentorship within
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29 Murphy JI. Using focused reflection and
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23 Resnik L, Hart DL. Using clinical outcomes 13-year old female with an incomplete spi-
31 Schrubbe KF. Mentorship: a critical com-
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clinical reasoning in undergraduate stu- 34 American Physical Therapy Association.
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metacognition. Accessed July 22, 2010.

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Appendix.
The Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT)a

I. Initial Data Gathering/Interview

a. History and present function

REFLECTION POINTS:
➢ Assess how the patient’s medical diagnosis affects your interview.
➢ How might your personal biases/assumptions affect your interview?
➢ Assessing the information you gathered, what do you see as a pattern or connection between the
symptoms?
➢ What is the value of the data you gathered?
➢ What are some of the judgments you can draw from the data? Are there alternative solutions?
➢ What is your assessment of the patient’s/caregiver’s knowledge and understanding of their diagnosis
and need for PT?
➢ Have you verified the patient’s goals and what resources are available?
➢ Based on the information gathered, are you able to assess a need for a referral to another health care
professional?

II. Generation of Initial Hypothesis

a. Body structures/functions

b. Impairments

c. Activity limitations

d. Participation restrictions

REFLECTION POINTS:
➢ Can you construct a hypothesis based on the information gathered?
➢ What is that based on (biases, experiences)?
➢ How did you arrive at the hypothesis? How can you explain your rationale?
➢ What about this patient and the information you have gathered might support your hypothesis?
➢ What do you anticipate could be an outcome for this patient (prognosis)?
➢ Based on your hypothesis, how might your strategy for the examination be influenced?
➢ What is your approach/planned sequence/strategy for the examination?
➢ How might the environmental factors affect your examination?
➢ How might other diagnostic information affect your examination?

(Continued)

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Appendix.
Continued

III. Examination
a. Tests and Measures

RELECTION POINTS:
➢ Appraising the tests and measures you selected for your examination, how and why did you select
them?
➢ Reflecting on these tests, how might they support/negate your hypothesis?
➢ Can the identified tests and measures help you determine a change in status? Are they able to detect a
minimum clinically important difference?
➢ How did you organize the examination? What might you do differently?
➢ Describe considerations for the psychometric properties of tests and measures used.
➢ Discuss other systems not tested that may be affecting the patient’s problem.
➢ Compare your examination findings for this patient with another patient with a similar medical
diagnosis.
➢ How does your selection of tests and measures relate to the patient’s goals?

(Continued)

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Appendix.
Continued

IV. Evaluation

HEALTH CONDITION

ACTIVITY (TASKS)
BODY STRUCTURES/FUNCTION PARTICIPATION
(IMPAIRMENTS) Abilities Limitations
Abilities Restrictions

ENVIRONMENTAL

Internal External

ⴙ ⴚ ⴙ ⴚ

(Continued)

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Clinical Reasoning and Reflection

Appendix.
Continued

IV. Evaluation (continued)

a. Diagnosis

b. Prognosis

REFLECTION POINTS:
➢ How did you determine your diagnosis? What about this patient suggested your diagnosis?
➢ How did your examination findings support or negate your initial hypothesis?
➢ What is your appraisal of the most important issues to work on?
➢ How do these relate to the patient’s goals and identified issues?
➢ What factors might support or interfere with the patient’s prognosis?
➢ How might other factors such as bodily functions and environmental and societal factors affect the
patient?
➢ What is your rationale for the prognosis, and what are the positive and negative prognostic indicators?
➢ How will you go about developing a therapeutic relationship?
➢ How might any cultural factors influence your care of the patient?
➢ What are your considerations for behavior, motivation, and readiness?
➢ How can you determine capacity for progress toward goals?

V. Plan of Care
a. Identify short-term and long-term goals

b. Identify outcome measures

c. PT prescription (frequency/intensity of service, include key elements)

REFLECTION POINTS:
➢ How have you incorporated the patient’s and family’s goals?
➢ How do the goals reflect your examination and evaluation (ICF framework)?
➢ How did you determine the PT prescription or plan of care (frequency, intensity, anticipated length of
service)?
➢ How do key elements of the PT plan of care relate back to primary diagnosis?
➢ How do the patient’s personal and environmental factors affect the PT plan of care?

(Continued)

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Appendix.
Continued

VI. Interventions
a. Describe how you are using evidence to guide your practice

b. Identify overall approach/strategy

c. Describe and prioritize specific procedural interventions

d. Describe your plan for progression

REFLECTION POINTS:
➢ Discuss your overall PT approach or strategies (eg, motor learning, strengthening).
y How will you modify principles for this patient?
y Are there specific aspects about this particular patient to keep in mind?
y How does your approach relate to theory and current evidence?
➢ As you designed your intervention plan, how did you select specific strategies?
➢ What is your rationale for those intervention strategies?
➢ How do the interventions relate to the primary problem areas identified using the ICF?
➢ How might you need to modify your interventions for this particular patient and caregiver? What are
your criteria for doing so?
➢ What are the coordination of care aspects?
➢ What are the communication needs with other team members?
➢ What are the documentation aspects?
➢ How will you ensure safety?
➢ Patient/caregiver education:
y What are your overall strategies for teaching?
y Describe learning styles/barriers and any possible accommodations for the patient and caregiver.
y How can you ensure understanding and buy-in?
y What communication strategies (verbal and nonverbal) will be most successful?

(Continued)

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Clinical Reasoning and Reflection

Appendix.
Continued

VII. Reexamination
a. When and how often

REFLECTION POINTS:
➢ Evaluate the effectiveness of your interventions. Do you need to modify anything?
➢ What have you learned about the patient/caregiver that you did not know before?
➢ Using the ICF, how does this patient’s progress toward goals compare with that of other patients with a
similar diagnosis?
➢ Is there anything that you overlooked, misinterpreted, overvalued, or undervalued, and what might you
do differently? Will this address any potential errors you have made?
➢ How has your interaction with the patient/caregiver changed?
➢ How has your therapeutic relationship changed?
➢ How might any new factors affect the patient outcome?
➢ How do the characteristics of the patient’s progress affect your goals, prognosis, and anticipated
outcome?
➢ How can you determine the patient’s views (satisfaction/frustration) about his or her progress toward
goals? How might that affect your plan of care?
➢ How has PT affected the patient’s life?

VIII. Outcomes
a. Discharge plan (include follow-up, equipment, school/work/community re-entry, etc)

REFLECTION POINTS:
➢ Was PT effective, and what outcome measures did you use to assess the outcome? Was there a
minimum clinically important difference?
➢ Why or why not?
➢ What criteria did you or will you use to determine whether the patient has met his or her goals?
➢ How do you determine the patient is ready to return to home/community/work/school/sports?
➢ What barriers (physical, personal, environmental), if any, are there to discharge?
➢ What are the anticipated life-span needs, and what are they based on?
➢ What might the role of PT be in the future?
➢ What are the patient’s/caregiver’s views of future PT needs?
➢ How can you and the patient/caregiver partner together for a lifetime plan for wellness?

IX. Mentor Feedback:

Strengths:

Opportunities for development:

a
PT⫽physical therapy, ICF⫽International Classification of Functioning, Disability and Health.

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